Closing the mental health gap to support good life chances for children and young people
Authors: Sophia M Varadkar, Pradnya Gadgil
Journal: The Lancet Global Health (2023)

In The Lancet Global Health, Mauricio Hoffmann and colleagues compare two widely used and already validated clinical tools, which use parental report to screen for mental health difficulties in children and young people to determine which would best predict future poor life outcomes (death, suicide attempts, severe self-harm, psychiatric inpatient admissions, and emergency department visits) or poor life chances (criminal conviction, substance misuse, and school dropout or expulsion).1Hoffman MS Pine DS Georgiade K et al.Comparing mental health semi-structured diagnostic interviews and symptom checklists to predict poor life outcomes: an 8-year cohort study from childhood to young adulthood in Brazil.Lancet Glob Health. 2023; (published online Nov 16.)https://doi.org/10.1016/S2214-109X(23)00462-XPubMed Google Scholar The first tool, the Developmental and Wellbeing Assessment (DAWBA), is a structured diagnostic interview that is widely used and considered pragmatic and feasible. The second tool, the Child Behaviour Checklist (CBCL) is a symptom checklist and is easier to administer than the DAWBA. The data were collected as part of a wider study, the Brazilian High-risk Cohort Study for Childhood Mental Health Conditions, a school-based observational cohort study following over 2500 school children since 2010. Both tools are useful, but the authors conclude that the CBCL is a significant predictor of poor life chances, whereas the DAWBA is not. The implication is that the CBCL is a lower-cost, easy-to-implement tool to identify those most in need of mental health support, to help prevent major adverse outcomes. The WHO Special Initiative for Mental Health was launched in 2019. In 2020, the COVID-19 pandemic precipitated an acute crisis on top of already considerable difficulties in child and adolescent mental health.2Morris J Fisher E Growing problems, in depth: the impact of Covid-19 on health care for children and young people in England.https://www.nuffieldtrust.org.uk/resource/growing-problems-in-detail-covid-19-s-impact-on-health-care-for-children-and-young-people-in-englandDate: Feb 18, 2022Date accessed: October 21, 2023Google Scholar In high-income countries, we saw already stretched or non-existent child and adolescent mental health services without resource or capacity, unable to meet the massive need. Worldwide, the treatment gap for mental health was always omnipresent: the National Mental Health Survey of India 2015–16 found the overall treatment gap to be 84·5%.3Gautham MS Gururaj G Varghese M et al.The National Mental Health Survey of India (2016): prevalence, socio-demographic correlates and treatment gap of mental morbidity.Int J Soc Psychiatry. 2020; 66: 361-372Crossref PubMed Scopus (84) Google Scholar Mental health concerns in children and young people were already increasing before the COVID-19 pandemic. The US Centers for Disease Control and Prevention (CDC) Youth Risk Behavior Surveillance System reported that 40% of children and young people in US high schools had feelings of sadness or hopelessness and suicidal thoughts in the 10 years preceding the pandemic.4Centers for Disease Control and PreventionYouth Risk Behavior Surveillance System (YRBSS).https://www.cdc.gov/healthyyouth/data/yrbs/index.htmDate: 2021Date accessed: October 21, 2023Google Scholar Diagnoses of anxiety increased by 29% and of depression by 27% between 2016 and 2020.5Lebrun-Harris LA Ghandour RM Kogan MD Warren MD Five-year trends in US children's health and well-being, 2016–2020.JAMA Pediatr. 2022; 176e220056Crossref PubMed Scopus (75) Google Scholar By 2021, the CDC reported that 30% of schoolgirls were contemplating suicide—a 60% increase in 10 years. The increase is a worldwide phenomenon, irrespective of socioeconomical and cultural factors. The latest UNICEF South Africa U-Report poll, published in October, 2023, continues to find 73% of children and young people aged 15–30 years saying they need mental health support but only 38% actively seeking help. A robust meta-analysis from India found depression prevalence at 27% and anxiety at 26% in rural adolescents.6Rajkumar E Julia GJ Sri Lakshmi K NV et al.Prevalence of mental health problems among rural adolescents in India: a systematic review and meta-analysis.Sci Rep. 2022; 1216573Crossref Scopus (0) Google Scholar We extrapolate from our experience in caring for children and young people with drug-resistant epilepsy; this disease is a paradigm of a global chronic disease, with high stigma and comorbidities including mental health and behavioural difficulties, but with real potential for meaningful treatment. Even before the pandemic, our international experience was that mental health disorders in long-term conditions in children and young people were overlooked and undertreated. Like Hoffmann and colleagues, we have seen complex assessments used as gatekeeping or barriers to accessing mental health services. Evidence-based psychological treatments for common mental health disorders (anxiety, depression, and disruptive behaviour disorders) in children and young people are not always offered. A common misconception continues that the physical health condition must be treated first; we believe treatment should be in parallel. The lack of integration of mental and physical health care is seen across high-income, middle-income, and low-income countries, and the associated stigma adds further to the impact of resource and capacity shortage. Although the globalisation of digital technology and social media is a likely factor in challenging the mental health of our children and young people, the change is here to stay. Middle-income and low-income populations, people in urban and rural settings, and those with low literacy have access to technology. In India, almost half of the rural population has internet access.7NielsenNielsen's Bharat 2.0 Study reveals a 45% growth in active internet users in rural India since 2019.https://www.nielsen.com/news-center/2022/nielsens-bharat-2-0-study-reveals-a-45-growth-in-active-internet-users-in-rural-india-since-2019Date: May, 2022Date accessed: October 31, 2023Google Scholar The incredible digital reach can bridge treatment gaps. We hope that telemedicine will improve accessibility for diagnosis and intervention, although careful evaluation of value in different settings will need to be shown.8National Institute for Health and Care ExcellenceEvidence standards framework for digital health technologies.www.nice.org.uk/corporate/ecd7Date: Aug 9, 2022Date accessed: October 28, 2023Google Scholar Importantly, there is an opportunity to overcome barriers of social stigma and literacy. Rather than widening the treatment gap, digital health might offer an opportunity to improve equity of access, including access to low cost and accessible electronically delivered assessment tools and virtually delivered modular assessments and treatments. There is a clear need for more resources to support mental health.9WHOWorld mental health report: transforming mental health for all. World Health Organization, Geneva2022Google Scholar Policies and budgetary allocations for mental health have traditionally been insufficient; before the COVID-19 pandemic, India spent less than 0·1% of its annual health budget on mental health.10Malhotra S Mental Health Care Act 2017 at five years of its existence.Indian J Psychiatry. 2023; 65: 971-973Crossref PubMed Scopus (0) Google Scholar Post pandemic, we hope increasing political prioritisation worldwide leads to increased funding for mental health. Nonetheless, there is an advantage in having reliable measures that can be administered with minimal training or independent of health-care professionals, whether in person, paper-based, or via digital health, to better focus the still limited resources for children and young people worldwide. All research at Great Ormond Street Hospital NHS Foundation Trust is supported by the National Institute for Health Research (NIHR) Great Ormond Street Hospital Biomedical Research Centre. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care. SMV is a co-applicant for the NIHR Programme Grant: Transforming the mental health treatment of young people with epilepsy. PJG declares no competing interests. Comparing mental health semi-structured diagnostic interviews and symptom checklists to predict poor life outcomes: an 8-year cohort study from childhood to young adulthood in BrazilClassifying children and adolescents based on a semi-structured diagnostic interview was not statistically different to symptom checklist in terms of test accuracy and predictive validity for relevant life outcomes. Classification based on symptom checklist might be a valid alternative to costly and time-consuming methods to identify young people at risk for poor life outcomes. Full-Text PDF Open Access